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Visual outcomes and complications following intraocular lens exchange in a pediatric population
Volume 15 Number 1 / February 2011 at a mean age of 45 months (range, 3 months to 9.6 years). Forty-nine (75%) were fully accommodative (FAET) while the remaining 16 (25%) were partially accommodative (PAET). During a mean follow-up of 10.2 years (range, 0 to 25.5 years), 41 (63%) of the children were able to eliminate their bifocal although one-third of these still required spectacle correction for distance esotropia. Children with PAET were more likely to eliminate their bifocals (p 5 0.14) than those with FAET during the follow-up period. Discussion: One in 5 children with accommodative esotropia had a high AC/A ratio in this population. Two of 3 children were able to eliminate their bifocal after approximately one decade, which was somewhat more common in children with partially accommodative esotropia. Conclusions: Most children with accommodative esotropia and a high AC/A ratio are able to eliminate their bifocal in their late teens, although many will continue to require spectacle correction for distance esotropia. 092 Telemedicine screening for ROP in Montana. Todd Murdock, Daniel Weaver Purpose: To demonstrate the feasibility of telemedicine screening for retinopathy of prematurity (ROP) by summarizing the results of our 3.5-year experience screening premature infants at a distant hospital in a rural western state. Methods: This was a retrospective review of all premature infants remotely screened for ROP at a level 3b neonatal intensive care unit (NICU) in Great Falls, Montana. The RetCam II imaging system was used to capture retinal images which were then posted on a secure server for evaluation by one of two pediatric ophthalmologists. Infants suspected to have ROP approaching the threshold for laser treatment were transferred to a hospital where a live exam was performed and treatment administered when indicated. All other infants received a live outpatient exam within 2 weeks of discharge. Results: 468 telemedicine exams were performed on 112 infants during the study period. Of nine infants transferred for worsening ROP, six ultimately required laser treatment, all having good outcomes. No cases of missed threshold ROP occurred. Discussion: In some rural settings, it can be particularly difficult to locate an appropriately trained ophthalmologist willing to screen for ROP. Transferring every infant needing ROP screening to another facility is both expensive and impractical. Telemedicine ROP screening is one potential solution to this problem. Our experience demonstrates the utility of telemedicine screening for ROP. Conclusions: In our experience, telemedicine screening for ROP has been effective in detecting ROP that will progress to threshold disease. There have been no adverse patient outcomes during the study period. 093 Accuracy of retinopathy of prematurity image-based diagnosis by pediatric ophthalmology fellows. Jane S. Myung, Robison V. P. Chan, Michael J. Espiritu, Steven L. Williams, David B. Granet, Thomas C. Lee, David J. Weissgold, Michael F. Chiang Purpose: To measure accuracy of image-based ROP diagnosis by pediatric ophthalmology fellows. Methods: An atlas of 804 retinal images was captured from 248 eyes of 67 premature infants with a wide-angle camera (RetCam-II). Images were uploaded to a study website, from which an expert pediatric retinal specialist and five pediatric ophthalmology fellows independently reviewed them. Two different retinal specialists experienced in ROP served as controls. Diagnostic accuracy by all subjects was calculated compared to the expert pediatric retinal specialist.
Journal of AAPOS
e25 Results: For detection of mild or worse ROP, mean sensitivity among fellows was 0.850 and specificity was 0.919. For detection of type-2 or worse ROP, mean sensitivity was 0.527 and specificity was 0.938. For detection of treatment-requiring ROP, mean sensitivity was 0.515 and specificity was 0.949. For the two retinal specialist controls, mean sensitivity for detection of type-2 or worse ROP was 0.844 and specificity was 0.855, and mean sensitivity for detection of treatment-requiring ROP was 1.000 and specificity was 0.908. Discussion: The supply of adequately-trained ophthalmologists willing to manage ROP is declining. In response, ophthalmologists without subspecialty training are managing ROP, and fellows are performing independent examinations in some centers. A previous study on retina fellows found limited diagnostic accuracy. Conclusions: Pediatric ophthalmology fellows demonstrated high specificity but lower sensitivity, particularly for clinically-significant disease, in image-based ROP diagnosis. This raises concerns about under-diagnosis of severe disease, has implications about quality of ROP screening by less experienced ophthalmologists and suggests a need for formalized training programs. 094 Incidence and severity of retinopathy of prematurity in premature infants with birth weight .1250 grams and/or gestational age .28 weeks. Mehul H. Nagarsheth, Alison S. Smith, Dashminder Singh, Faruk H. Orge, Jeffrey N. Bloom Purpose: Retinopathy of prematurity (ROP) is a vision-threatening disorder of preterm infants. Current guidelines recommend that selected infants with birth weight 1500-2000 g or gestational age more than 32 weeks with an unstable clinical course should have retinal screening examinations to detect ROP. In our study, we reviewed ROP examinations in our Level III NICU to determine upper limits of birth weight and gestational age for screening purposes. Methods: A retrospective chart review was performed for all premature infants admitted from January 1, 1997 to September 30, 2008. 950 charts from this time period were reviewed. Infants with birth weights greater than 1250 g and/or gestational age greater than 28 weeks were noted and followed for regression or treatment of ROP. Particular attention was paid to infants with birth weight greater than 1500 g and/or gestational age greater than 30 weeks. Results: We identified 71 subjects with birth weights of 1250 g or greater, 33 subjects with birth weights equal to or greater than 1500 g, and 152 subjects born at 28 weeks gestational age or greater. None of the 33 subjects with birth weights greater than or equal to 1500 g required laser ROP treatment. Discussion: Our data suggest that, unlike current guidelines above, a birth weight upper limit \1500 g is unlikely to miss cases of ROP requiring laser therapy. Conclusions: With a screening birth weight upper limit of 1500 grams, ophthalmologists would perform less ROP screening examinations. This in turn would reduce health-care cost and physical stress to premature infants. 095 Visual outcomes and complications following intraocular lens exchange in a pediatric population. Kalpana Narendran, Sandra C. Ganesh, Rajesh Prabu, Ramakrishnan Subramaniam, Ajay Harish Purpose: To assess the indications, compare pre and postoperative visual acuity and to assess the complications following intraocular lens exchange in a pediatric population. Methods: Medical records of children less than 15 years who had undergone intraocular lens exchange from Jan 2008 to Jan 2009 were
e26 retrospectively reviewed. The parameters studied included age, sex, pre and post operative visual acuity and refraction and indication for intraocular lens exchange .Inclusion criteria was a minimal period of six month follow up following surgery. All patients were operated on by a single experienced surgeon. Results: 11 eyes of 10 children were studied. Mean age of the study population was 8 years (range, 3 to 13). Male to female ratio was 1:1. Indications for surgery included posterior capsular opacification with optic capture (54%), decenteration of lens (18%), myopic shift (9%), lens pitting (9%) and sequelae of post operative inflammation (9%). Wilcoxon signed rank test was used to compare the pre and post operative best corrected visual acuity which showed a statistically significant improvement (Post- op day 1 – p-value 5 0.11 and 1 month post- op p-value 5 0.005). 4 cases with poor vision after surgery were due to cystoids macular edema (9%) and amblyopia due to PHPV (9%) and nystagmus (18%). Discussion: In our study population the best corrected visual acuity improved significantly following lens exchange and the overall complication rates were low. Conclusions: Though technically challenging, intraocular lens exchange can be a visually rewarding procedure in experienced hands. 096 Uncorrected visual acuity in children with monofocal pseudophakia. Bharti Nihalani-Gangwani, Deborah K. VanderVeen Introduction: Only 9% adults are found to have uncorrected visual acuity (VA) of .20/40 for distance and near with monofocal introcular lens (IOL). Use of multifocal or accommodative IOLs is controversial in children. We report uncorrected distance and near VA in children with monofocal IOL. Methods: Records of children .5 years age who received monofocal IOL targeted for emmetropia within 1 D spherical equivalent were reviewed. Eyes with other causes of vision worse than 20/40 (amblyopia, developmental delay, optic atrophy) were excluded. Vision was tested using M&S system with Snellen equivalent for distance, and standard Jaeger's near card for near VA. Uncorrected VA for each eye and under binocular conditions and refractive error was recorded. Results: 41 eyes of 25 children had uncorrected distance and near VA recorded. Mean age was 11.2 3.6 years. 20 eyes (48.8%) had VA .20/40 at distance and near, 11 had . 20/40 for distance only, 6 had .20/40 for near only, and 4 had \ 20/40 for distance and near. 30 eyes (70%) had WTR astigmatism. All but 2 eyes (95%) were 20/ 70 or better distance and near without correction. In children with bilateral pseudophakia, 12/16 (75%) were 20/40 or better distance and near without correction, with approximately symmetric refractive error (0.2 1.2 D). Conclusions: Monofocal IOLs provide good (.20/40) distance and near uncorrected VA in almost 50% pediatric eyes when the target is within 1 D of emmetropia. 097 Endoscopic goniotomy (EG): An alternative approach for goniotomy. Faruk H. Orge Purpose: The main stay of treatment of congenital glaucoma is surgical. Goniotomy tends to be the preferred initial angle reconstructing surgery when the cornea is clear. For the patients with cloudy cornea and poor intraocular pressure control (IOP) despite trabeculotomy, so far no other angle surgery has been routinely performed. We present a case series of useful application of endoscope in goniotomy. Methods: This is a retrospective case analysis of 3 patients (4 eyes) with congenital glaucoma. 2 of the patients were with cloudy cor-
Volume 15 Number 1 / February 2011 neas at the time of presentation. The last patient had Axenfeld-Rieger syndrome with extensive irido-corneal adhesions blocking the angle view. Despite trabeculotomies and consecutive maximal medical management the IOP were not controlled and the angle was not visible via gonioscopy in all the cases. Results: Case 1 the IOP decreased from 29 mm Hg to 15 mm Hg in the left eye and from 25 mm Hg to 15 mm Hg in the right eye with EG (follow-up, 26 months). The second case received temporal and superior trabeculotomy. With consecutive EG, IOP decreased from mid 30's to mid-teens with medical treatment (follow up 15 months). In the last case angle was not visible and despite trabeculotomy and goniotomy procedures ended up needing tube shunt procedure. But the inferionasal angle could only be visualized with the help of an endoscope (follow up 7 months). Discussion: No complications were noted in any of the cases. Conclusions: Endoscopic goniotomy is an effective surgical option in congenital glaucoma with cloudy corneas. 098 An eye into the heart—retinal vascular changes in Kawasaki syndrome as a marker of coronary artery disease. Audrey Pang, SeoWei Leo, Terence Lim, Tien-Yin Wong Purpose: Kawasaki disease (KD), a multisystem vasculitis of unknown aetiology, is the commonest cause of acquired childhood heart disease in the developed world. We hypothesize that retinal vascular changes may be used as a surrogate marker for attendant coronary artery changes. The current strategy of screening for coronary anomalies with transthoracic echocardiography fails to detect coronary artery disease in distal coronary vessels. Better risk prognostication will help clinicians to decide when to use more invasive CT-angiograms or fluoroscopy-based contrast angiograms. Methods: The subjects had high resolution digital retinal photography. The diameters of all arterioles and venules coursing through a specified area one-half to one disc diameter from the optic disc will be measured with a computer program (IVAN), according to a standard protocol. Central retinal arteriolar equivalent (CRAE), central retinal venular equivalent (CRVE), arteriole-to-venule ratio (AVR) were calculated for each retina photo. Results: 8 patients with KD and 24 controls with a mean age of 12.4 years were examined. KD subjects had mean CRAE of 161.8 mm and AVR of 0.73, which were statistically significant from controls who had mean CRAE of 150 mm (p 0.046) and AVR of 0.66 (p 5 0.017). There was no difference in CRVE in KD subjects (221.5 mm) and controls (226.9 mm) (p 5 0.465). Conclusions: KD is associated with larger retinal arteriolar caliber. There is no correlation with retinal venular caliber, which is increased in systemic inflammation. Retinal arteriolar dilation and increased AVR may be surrogate markers for coronary artery changes in Kawasaki disease. 099 Oral propranolol for treating orbital lymphangioma: Success in a difficult case as third-line therapy. Daniel J. Pierre, Faruk H. Orge, David S. Bardenstein Introduction: Orbital lymphatic malformations are difficult to surgically eradicate, and surgical courses can be complicated. Despite best conventional efforts, cases can still result in sight-threatening conditions in affected children. We report the successful use of propranolol to treat an orbital lymphatic malformation as third-line therapy. Methods: A 14-month-old African American child had an extensive, biopsy proven, orbital microcystic lymphatic malformation, infiltrating all the structures in the orbit, lower and upper lid. The patient was at risk of anisometropic and deprivation amblyopia due to
Journal of AAPOS
Journal of AAPOS
e25 Results: For detection of mild or worse ROP, mean sensitivity among fellows was 0.850 and specificity was 0.919. For detection of type-2 or worse ROP, mean sensitivity was 0.527 and specificity was 0.938. For detection of treatment-requiring ROP, mean sensitivity was 0.515 and specificity was 0.949. For the two retinal specialist controls, mean sensitivity for detection of type-2 or worse ROP was 0.844 and specificity was 0.855, and mean sensitivity for detection of treatment-requiring ROP was 1.000 and specificity was 0.908. Discussion: The supply of adequately-trained ophthalmologists willing to manage ROP is declining. In response, ophthalmologists without subspecialty training are managing ROP, and fellows are performing independent examinations in some centers. A previous study on retina fellows found limited diagnostic accuracy. Conclusions: Pediatric ophthalmology fellows demonstrated high specificity but lower sensitivity, particularly for clinically-significant disease, in image-based ROP diagnosis. This raises concerns about under-diagnosis of severe disease, has implications about quality of ROP screening by less experienced ophthalmologists and suggests a need for formalized training programs. 094 Incidence and severity of retinopathy of prematurity in premature infants with birth weight .1250 grams and/or gestational age .28 weeks. Mehul H. Nagarsheth, Alison S. Smith, Dashminder Singh, Faruk H. Orge, Jeffrey N. Bloom Purpose: Retinopathy of prematurity (ROP) is a vision-threatening disorder of preterm infants. Current guidelines recommend that selected infants with birth weight 1500-2000 g or gestational age more than 32 weeks with an unstable clinical course should have retinal screening examinations to detect ROP. In our study, we reviewed ROP examinations in our Level III NICU to determine upper limits of birth weight and gestational age for screening purposes. Methods: A retrospective chart review was performed for all premature infants admitted from January 1, 1997 to September 30, 2008. 950 charts from this time period were reviewed. Infants with birth weights greater than 1250 g and/or gestational age greater than 28 weeks were noted and followed for regression or treatment of ROP. Particular attention was paid to infants with birth weight greater than 1500 g and/or gestational age greater than 30 weeks. Results: We identified 71 subjects with birth weights of 1250 g or greater, 33 subjects with birth weights equal to or greater than 1500 g, and 152 subjects born at 28 weeks gestational age or greater. None of the 33 subjects with birth weights greater than or equal to 1500 g required laser ROP treatment. Discussion: Our data suggest that, unlike current guidelines above, a birth weight upper limit \1500 g is unlikely to miss cases of ROP requiring laser therapy. Conclusions: With a screening birth weight upper limit of 1500 grams, ophthalmologists would perform less ROP screening examinations. This in turn would reduce health-care cost and physical stress to premature infants. 095 Visual outcomes and complications following intraocular lens exchange in a pediatric population. Kalpana Narendran, Sandra C. Ganesh, Rajesh Prabu, Ramakrishnan Subramaniam, Ajay Harish Purpose: To assess the indications, compare pre and postoperative visual acuity and to assess the complications following intraocular lens exchange in a pediatric population. Methods: Medical records of children less than 15 years who had undergone intraocular lens exchange from Jan 2008 to Jan 2009 were
e26 retrospectively reviewed. The parameters studied included age, sex, pre and post operative visual acuity and refraction and indication for intraocular lens exchange .Inclusion criteria was a minimal period of six month follow up following surgery. All patients were operated on by a single experienced surgeon. Results: 11 eyes of 10 children were studied. Mean age of the study population was 8 years (range, 3 to 13). Male to female ratio was 1:1. Indications for surgery included posterior capsular opacification with optic capture (54%), decenteration of lens (18%), myopic shift (9%), lens pitting (9%) and sequelae of post operative inflammation (9%). Wilcoxon signed rank test was used to compare the pre and post operative best corrected visual acuity which showed a statistically significant improvement (Post- op day 1 – p-value 5 0.11 and 1 month post- op p-value 5 0.005). 4 cases with poor vision after surgery were due to cystoids macular edema (9%) and amblyopia due to PHPV (9%) and nystagmus (18%). Discussion: In our study population the best corrected visual acuity improved significantly following lens exchange and the overall complication rates were low. Conclusions: Though technically challenging, intraocular lens exchange can be a visually rewarding procedure in experienced hands. 096 Uncorrected visual acuity in children with monofocal pseudophakia. Bharti Nihalani-Gangwani, Deborah K. VanderVeen Introduction: Only 9% adults are found to have uncorrected visual acuity (VA) of .20/40 for distance and near with monofocal introcular lens (IOL). Use of multifocal or accommodative IOLs is controversial in children. We report uncorrected distance and near VA in children with monofocal IOL. Methods: Records of children .5 years age who received monofocal IOL targeted for emmetropia within 1 D spherical equivalent were reviewed. Eyes with other causes of vision worse than 20/40 (amblyopia, developmental delay, optic atrophy) were excluded. Vision was tested using M&S system with Snellen equivalent for distance, and standard Jaeger's near card for near VA. Uncorrected VA for each eye and under binocular conditions and refractive error was recorded. Results: 41 eyes of 25 children had uncorrected distance and near VA recorded. Mean age was 11.2 3.6 years. 20 eyes (48.8%) had VA .20/40 at distance and near, 11 had . 20/40 for distance only, 6 had .20/40 for near only, and 4 had \ 20/40 for distance and near. 30 eyes (70%) had WTR astigmatism. All but 2 eyes (95%) were 20/ 70 or better distance and near without correction. In children with bilateral pseudophakia, 12/16 (75%) were 20/40 or better distance and near without correction, with approximately symmetric refractive error (0.2 1.2 D). Conclusions: Monofocal IOLs provide good (.20/40) distance and near uncorrected VA in almost 50% pediatric eyes when the target is within 1 D of emmetropia. 097 Endoscopic goniotomy (EG): An alternative approach for goniotomy. Faruk H. Orge Purpose: The main stay of treatment of congenital glaucoma is surgical. Goniotomy tends to be the preferred initial angle reconstructing surgery when the cornea is clear. For the patients with cloudy cornea and poor intraocular pressure control (IOP) despite trabeculotomy, so far no other angle surgery has been routinely performed. We present a case series of useful application of endoscope in goniotomy. Methods: This is a retrospective case analysis of 3 patients (4 eyes) with congenital glaucoma. 2 of the patients were with cloudy cor-
Volume 15 Number 1 / February 2011 neas at the time of presentation. The last patient had Axenfeld-Rieger syndrome with extensive irido-corneal adhesions blocking the angle view. Despite trabeculotomies and consecutive maximal medical management the IOP were not controlled and the angle was not visible via gonioscopy in all the cases. Results: Case 1 the IOP decreased from 29 mm Hg to 15 mm Hg in the left eye and from 25 mm Hg to 15 mm Hg in the right eye with EG (follow-up, 26 months). The second case received temporal and superior trabeculotomy. With consecutive EG, IOP decreased from mid 30's to mid-teens with medical treatment (follow up 15 months). In the last case angle was not visible and despite trabeculotomy and goniotomy procedures ended up needing tube shunt procedure. But the inferionasal angle could only be visualized with the help of an endoscope (follow up 7 months). Discussion: No complications were noted in any of the cases. Conclusions: Endoscopic goniotomy is an effective surgical option in congenital glaucoma with cloudy corneas. 098 An eye into the heart—retinal vascular changes in Kawasaki syndrome as a marker of coronary artery disease. Audrey Pang, SeoWei Leo, Terence Lim, Tien-Yin Wong Purpose: Kawasaki disease (KD), a multisystem vasculitis of unknown aetiology, is the commonest cause of acquired childhood heart disease in the developed world. We hypothesize that retinal vascular changes may be used as a surrogate marker for attendant coronary artery changes. The current strategy of screening for coronary anomalies with transthoracic echocardiography fails to detect coronary artery disease in distal coronary vessels. Better risk prognostication will help clinicians to decide when to use more invasive CT-angiograms or fluoroscopy-based contrast angiograms. Methods: The subjects had high resolution digital retinal photography. The diameters of all arterioles and venules coursing through a specified area one-half to one disc diameter from the optic disc will be measured with a computer program (IVAN), according to a standard protocol. Central retinal arteriolar equivalent (CRAE), central retinal venular equivalent (CRVE), arteriole-to-venule ratio (AVR) were calculated for each retina photo. Results: 8 patients with KD and 24 controls with a mean age of 12.4 years were examined. KD subjects had mean CRAE of 161.8 mm and AVR of 0.73, which were statistically significant from controls who had mean CRAE of 150 mm (p 0.046) and AVR of 0.66 (p 5 0.017). There was no difference in CRVE in KD subjects (221.5 mm) and controls (226.9 mm) (p 5 0.465). Conclusions: KD is associated with larger retinal arteriolar caliber. There is no correlation with retinal venular caliber, which is increased in systemic inflammation. Retinal arteriolar dilation and increased AVR may be surrogate markers for coronary artery changes in Kawasaki disease. 099 Oral propranolol for treating orbital lymphangioma: Success in a difficult case as third-line therapy. Daniel J. Pierre, Faruk H. Orge, David S. Bardenstein Introduction: Orbital lymphatic malformations are difficult to surgically eradicate, and surgical courses can be complicated. Despite best conventional efforts, cases can still result in sight-threatening conditions in affected children. We report the successful use of propranolol to treat an orbital lymphatic malformation as third-line therapy. Methods: A 14-month-old African American child had an extensive, biopsy proven, orbital microcystic lymphatic malformation, infiltrating all the structures in the orbit, lower and upper lid. The patient was at risk of anisometropic and deprivation amblyopia due to
Journal of AAPOS